Service Recipient Paperwork Questionnaire

Service Recipient Questionnaire
The following information helps us get to know you better. It will be used to assist in selecting caregivers who are the best possible match for your needs from the very start.

Once you and Prestige Homecare have reached a verbal agreement to begin services, additional documentation required by the State of Tennessee will need to be completed.

Would you like it to sound warmer and more personal (for client-facing use) or more formal (for inclusion in official paperwork)?
Name of Service Recipient*

First NameLast Name
Phone Number*

Area CodePhone Number
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Date of Admission/Services Began*

MonthDayYear
Date
Sex*
Date of Birth*
Referred by
Check all that apply
Chronic Illnesses:*
Acute Conditions:
Describe above conditions*
Surgeries*
Check all that apply*
Describe above conditions*
Please list all medications and dosages
Check all desired services that apply*
Assessment of Needs
Describe other history, habits, behaviors, etc.*
List likes and dislikes*
Source of Financial Support/Financial Arrangements
Is service recipient responsible for payment of services?*

YesNo
If the service recipient does not manage his/her own finances, list the name of the person/agency responsible for payment of services*
Legal Documents
Is the service recipient legally competent?*

YesNo
Does the service recipient have DNR - Do Not Resuscitate?*

YesNoUnsure
Below are copies of our Grievance Procedures, as well as our Policy and Procedure manuals for your review
Should be Empty:

Service Recipient Questionnaire

Below are copies of our Grievance Procedures, as well as our Policy and Procedure manuals for your review